title: Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group.
abstract: BACKGROUND
  In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy.
  
  
  CONCLUSIONS
  In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.
authors.affiliation: Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy.
authors.forename: Salomone
authors.initials: S
authors.lastname: Di Saverio
authors.affiliation: General Surgery I, Ospedali Riuniti di Bergamo, Bergamo, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: Coccolini
authors.affiliation: Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy.
authors.forename: Marica
authors.initials: M
authors.lastname: Galati
authors.affiliation: Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy.
authors.forename: Nazareno
authors.initials: N
authors.lastname: Smerieri
authors.affiliation: Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA.
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.affiliation: General Surgery I, Ospedali Riuniti di Bergamo, Bergamo, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Ansaloni
authors.affiliation: Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy.
authors.forename: Gregorio
authors.initials: G
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authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: George C
authors.initials: GC
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authors.affiliation: Department of Surgery, Macerata Hospital, Via Santa Lucia 2, 62100 Macerata, Italy.
authors.forename: Massimo
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authors.affiliation: Department of Surgery, John Hunter Hospital and University of Newcastle, Locke Bag 1 Hunter Region Maile Centre, Newcastle, NSW 2310, Australia.
authors.forename: Cino
authors.initials: C
authors.lastname: Bendinelli
authors.affiliation: Division of Trauma Surgery, University of Campinas, Campinas, SP, Brazil.
authors.forename: Gustavo Pereira
authors.initials: GP
authors.lastname: Fraga
authors.affiliation: Upper GI Unit, Department of Surgery, Frenchay Hospital, North Bristol, NHS Trust, Bristol, UK.
authors.forename: Michael D
authors.initials: MD
authors.lastname: Kelly
authors.affiliation: Department of Surgery, University of Florida, Gainesville, FL 32610-0254, USA.
authors.forename: Frederick A
authors.initials: FA
authors.lastname: Moore
authors.affiliation: Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy.
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Mandalà
authors.affiliation: Department of General and Emergency Surgery, Associated Hospitals "Villa Sofia - Cervello", Palermo, Italy.
authors.forename: Stefano
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authors.lastname: Mandalà
authors.affiliation: Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Masetti
authors.affiliation: Emergency and Trauma Surgery Unit, Departments of Emergency and Surgery, Maggiore Hospital Trauma Center, Bologna, Italy.
authors.forename: Elio
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authors.lastname: Jovine
authors.affiliation: Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy.
authors.forename: Antonio D
authors.initials: AD
authors.lastname: Pinna
authors.affiliation: Division of General Surgery, University of Pittsburgh Physicians, Pittsburgh 15213 PA, USA.
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Peitzman
authors.affiliation: Emergency Surgery, Department of Abdominal Surgery, Meilahti Hospital, University of Helsinki, Haartmaninkatu 4, 340, Helsinki FIN-00029 HUS, Finland.
authors.forename: Ari
authors.initials: A
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authors.affiliation: Washington Cancer Institute, Washington Hospital Center, Washington, 20010 DC, USA.
authors.forename: Paul H
authors.initials: PH
authors.lastname: Sugarbaker
authors.affiliation: Department of Surgery, Radboud University Nijmegen Medical Centre, P.O. Box 9101 6500 HB, Nijmegen, The Netherlands.
authors.forename: Harry Van
authors.initials: HV
authors.lastname: Goor
authors.affiliation: Department of Surgery, Denver Health, University of Colorado Health Sciences Denver, Denver Health Medical Center, 777 Bannock Street, Denver CO 80204, USA.
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.affiliation: Department of Surgery, Erasmus University Medical Center, PO Box 2040 3000 CA, Rotterdam, The Netherlands.
authors.forename: Johannes
authors.initials: J
authors.lastname: Jeekel
authors.affiliation: Emergency Surgery Unit, Department of General and Multivisceral Transplant Surgery, S Orsola Malpighi University Hospital, Bologna, Italy.|Department of Emergency and Trauma Surgery, Maggiore Hospital of Parma, Parma, Italy.
authors.forename: Fausto
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authors.lastname: Catena